Cardiac Rehabilitation In India

A way to go

Cardiac rehabilitation is recognized as an integral component of patient care with CVS diseases. Its gaining popularity over the globe in heart failure patients is new and encouraging. Its utilization in India is still under used because of many factors but the main is, lack of interest of cardiologist and scarcity of physiotherapist showing interest in the field. It needs more lot of work up to bloom the cardiac rehabilitation in India.

Cardiac rehabilitation is a program designed in 1930s to help patients recovering from cardiac conditions. Earlier bed rest and restricted activity had always been a choice in management of cardiac patients. But as with the introduction of CR program in early years to now there has been a major progression and a change in the lines of treatment of cardiac patients.

Nowadays CR has been evolved into a comprehensive program that helps patients not only to recover physically but also make them more aware of their CVS disease and how to improve on their heart health. Patients get to understand that there is not only medications that can keep a control on their disease but their own efforts on lifestyle change can improve their quality of life and can also reduce a risk of a future event.

Cardiac rehabilitation is increasingly recognized as an integral component of the patient care with CVS diseases. Its application is a class 1 recommendation in most cardiovascular clinical practice guidelines.

CORE COMPONENT OF CARDIAC REHABILITATION
The core components of cardiac rehabilitation and secondary prevention are detailed outlined in a scientific statement from American Heart Association and American Association of Cardiovascular and pulmonary rehabilitation and highlight the integral role of cardiac rehabilitation in secondary prevention of CVS disease.

Physiological parameters focus on improvement in exercise Habits and exercise tolerance and optimization of coronary risk factors including improvement in lipid and lipoproteins, body weight, blood glucose levels and cessation of smoking. An important role especially for elderly is functional independence.

CARDIAC REHABILITATION POST PCI
PCI is a safe, effective and non surgical treatment of CAD .The demand has been exponentially increased since 1980, which has become the choice of treatment for many individuals with CAD.PCI aims at lessening disease progression and improving the cardiac functional status in these individuals. Exercise is a central component of any cardiac prevention and rehabilitation strategy.

Individual exercise programs that incorporate physical activity and counseling can improve clinical outcomes in these patients. Epidemiological data indicates the benefits of exercise in improving the life quality and reducing the incidence of coronary heart disease in the population and mortality. We need to focus on Cardiac rehabilitation as a secondary prevention program specially in post PCI patients, the healthy future lies within downstream implementation of CR ,to reduce the risk of developing CVD.

ROLE OF CARDIAC REHABILITATION IN HEART FAILURE
Heart failure is a major health burden which is constantly on the rise all over the world .It is the most common cause of hospitalization. Annual hospital discharges in patients with a primary diagnosis of HF have risen steadily since 1975, and now exceeded 1 million discharges per year.

HF is primarily a disease of elderly that affects about 10% of men and 8% of women over the age of 60yrs , and its prevalence rises with the age and has risen overall. Developed nations have adapted series of strategies of risk stratification, prevention, education and treatment.

In Asian countries there is a dearth of data regarding incidence or prevalence of HF. The lifetime risk of HF increases with age. The number of people above 60yrs of age in India is projected to increase from 105 million in 2011 to 376 million in 2051.Interwine in this phenomenon is the increasing financial burden of the country and individual impairments resulting from this chronic disease, which is evident as exercise intolerance due to dyspnoea and fatigue.

Refined controlled studies have been designed to evaluate exercise Training as a therapeutic intervention in the HF population suggests positive outcome in functional capacity, symptoms and quality of life with training the patient on tailor made exercise regimen.

Exercise training is recommended by the American College Of Cardiology and AHA at a class 1 level. The benefits of exercise training in patients with HF include an improvement in exercise. Tolerance as assessed not only by exercise duration but more important by peak VO2. Significant differences is also been measured by 6 MWT on ventilatory threshold.

It also affects Central hemodynamic functions; autonomic nervous system function, peripheral vascular and muscle function as well as exercise capacity.

Number of evidences supports the benefits and safety of an exercise training program for the stable, systolic HF patient who is receiving optimal medical treatment .Functional capacity improves symptoms of dyspnoea and fatigue shrinks and self report quality of life benefits.

Several small randomized trials have not only found improvement in peak exercise capacity but a modification of multiple measures of metabolic functions, vascular tone, cytokine production and neural activation.

All suggest an important role for exercise in the interruption and improvement in the major limiting symptoms of HF known as exercise Intolerance.

WHERE THE PROBLEM LIES? (Author view)

I personally have a strong sense of belief that in India we are only concentrating on curing the disease disregard of exploring its pattern or recurrence schedule. Patient is getting readmitted with fresh blockages after a certain amount of time, may be at a different area of an artery.

The steps taken in direction of educating the patient about do’s and don’ts to prevent blockages are still a way behind. According to a report submitted by National interventional council of Cardio logical Society of India, presented a data of various forms of cardiac interventions done in India in year 2011. A total of 152,332 PCI procedures were performed in 332 centers. There was a growth of 28.8% as compared to previous year data. 13.6% was done in patients aged less than 40years and 14.5% was done in patients aged greater than 70 years. In conclusions they had been clearly mentioning the exponential increase each year of the PCI procedures and the trend of younger population getting affected.

The cause for the above can be many, some explained and some may be idiopathic. My single point agenda is after knowing all the data and its increasing trend how many cardiac hospitals are showing up their interest in Cardiac Rehabilitation and how many centers have actually come up with it. The number is deplorable. The post intervention cardiac care needs to be more specific and we cannot keep continuing ICU physiotherapy at the name of cardiac rehabilitation. I feel in India we are concentrating only on phase of 1 of cardiac rehabilitation when the patient is very much in the hospital but the other 3 phases are kept untouched where we be keeping the right track of patients going to work and enjoying all his recreational activities/hobbies.

Suggestive of all the benefits of exercising in HF, the emphasis is still very low or under prevalent in India.Now if we talk about heart failure patients, we all know there s much less we can actually do in them and as the disease progresses the situation of the patient becomes more and more miserable. The class of dyspnoea increases from NYHA 1 to NYHA 4 and so do the activity intolerance. We have still been more keen at providing rest to the patients of heart failure rather than putting them for a balanced amount of activities where they can keep up their tone and strength of muscle intact without going out of breath and excessively tired .The key reason to this is lack of facilities for cardiac rehabilitation is the lack of awareness amongst cardiologist and masses for the same. We are not able to come out of this mindset of REST after any CVD.

Comparing ourselves to west where every cardiac patient is receiving cardiac rehabilitation, as the starters we can at least put priority patients of heart failure in cardiac rehabilitation so that their wait for LVAD or Heart transplant doesn’t become unmanageable.

We definitely need more of the therapist showing interest in this under developed cardiac rehabilitation in India and more of the cardiologist backing it up to provide quality of life style and help the patient accommodating their dyspnoea and deconditioned state of health. The future of cardiovascular disease treatment is a whole package of curative, preventive and providing a more conditioned state of health to its patients, where symptoms can be managed as closely as possible.

Technology can provide us an edge if used properly and its power can be capitalized soon. Use of cell phones, internet and other devices provide us opportunities to engage patients in healthy lifestyle and can help us keeping an eye on their progress. Cardiac rehabilitation needs to be added both as a part of treatment as well as prevention then only we will be able to change the face of rehabilitation in India.

Hope this article will build a new wave for starting cardiac rehabilitation at a level where we all will contribute to a better treatment approach and a healthier lifestyle for all our cardiac patients.

REFERENCES
The Journal of biomedical research
Journal of American college of cardiology
Indian heart journal
American heart journal
European heart journal

Kanchan Anand, working as a Cardiac Rehabilitation Incharge at Fortis Escorts Heart Institute, New Delhi, India. I am specifically working for post PCI , Post surgical and stable LVF patients who either needs to change their lifestyle to prevent cardiac diseases or needs to be conditioned in a way to lead, as healthy life style as possible with Cardiovascular diseases.